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Hardcover

Overview

Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises

"Medical science has always promised  and often delivered  a longer, better life. But as the pace of science accelerates, do our expectations become unreasonable, fueled by an industry bent on profits and a media desperate for big news?

Hope or Hype is a taboo-shattering look at what drives the American obsession with medical "miracles," exposing the equipment manufacturers and pharmaceutical companies; doctors and hospitals too quick to order surgery; the politicians; the press; and our own "technoconsumption" mindset. The authors spread blame for the parade of so-called miracle cures that too often are marginally effective at best  and sometimes downright dangerous. They examine consumers’ eager embrace of medical advances, and present riveting stories of the conscientious doctors and researchers who blew the whistle on ineffective treatments. Finally, they provide sane, practical recommendations for the adoption of new developments.

The consequences of questionable practices include costly recalls, billions in wasted money, and the pain and suffering of innumerable patients and their families. In short, they must stop."

Product Details

About the Author

Dr. Richard Deyo and Dr. Richard Patrick (Seattle, WA) are both professors at the University of Washington. Deyo was co-recipient of the Nellie Westerman Prize for research in medical ethics. He directs a fellowship program for policy-relevant research training, as well as the university’s Center for Cost and Outcomes Research. Patrick is noted for his work on the links between quality of life, cost-effectiveness, and health policy. He has worked on drug studies for a wide variety of illnesses, and is a member of the Institute of Medicine, the most prestigious organization of health experts in the U.S.

AMACOM Books

Chapter One

I remembered an Irish woman who once said to me, "you know, if only you doctors could find a cure for these wretched antibiotics, you would be doing us all a good turn." -John Lister

There were other tests, some of which seemed to me to be more an assertion of the clinical capability of the hospital than of concern for the well-being of the patient. -Norman Cousins

As with buying a house or eating ice cream, it seems that getting more of a good thing is always better. Most of us assume that more medical care can only be a good thing. Americans are convinced that American medicine is the best because we get the most, and that the more we spend for medical care, the better it is.

For many basic medical services, this holds true. Childhood vaccinations, antibiotics for life-threatening infections, and surgery for appendicitis or heart disease can be lifesaving. At a population level, better access to basic services makes a big difference.

But as a nation, we may be at a point of diminishing returns. Increasing our expenditures on health care beyond a certain point may not improve the health of the nation one whit. There could even be a point where spending more for tests, drugs, and surgery will make things worse, leading to irrelevant findings, avoidable side effects, and unnecessary surgery.

Whether, as a society, we've reached that point is a matter of dispute. Everyone in the health-care industry-drug and device makers, hospitals, nurses and doctors-benefits financially when people spend more on medical care. They're quick to agree that more is better. With almost 15 percent of the economy going into health care, a huge number of American jobs depend on this idea. So it's no surprise that any suggestion to the contrary meets stiff resistance.

Even if our society as a whole has reached a point of diminishing returns with regard to health-care costs, some individuals may not be at that point. Someone with no insurance or with limited access to care may be in a very different situation. If such a person were able to make additional expenditures on health care, those expenditures might buy significantly better health. But those who are well insured and face no barriers to care may often be at the point of diminishing returns, or even beyond. For these people, added expenditures are more likely to buy unnecessary tests or treatments, some of which have unintended consequences.

Even if buying more health care is expensive, it often seems that cost is no object. That's because insurance-meaning everyone else-is subsidizing the bills. But those who pay the lion's share of the bills, including major employers, Medicare, and Medicaid, may be more skeptical. Many are wondering if we've collectively reached a plateau of benefit for cost. A few heretics suspect that we've actually passed the point of diminishing returns and are at a point where more expenditures buy worse health, instead of better health, for the public at large.

In the 1970s, the RAND Corporation started a novel experiment, comparing the effects of free medical care to those of insurance that required patients to pay a fraction of the cost. They found that people who got free medical care used much more. For poor people, that was good. Better access to care resulted in better health. But for people with average incomes, the added expenditures didn't improve their health at all. In fact, their increased use of medical care paradoxically led to more worry, pain, and activity limitations.

A more recent study was more narrowly focused, but also suggested that beyond a certain point, more access to medical technology doesn't help. This study focused on the highly specialized world of neonatal intensive care units. These units are rich in medical technology-full of heart monitors, breathing machines, and intravenous infusion devices. These units are where premature babies (sometimes unbelievably small) achieve seemingly miraculous survival. Are more neonatologists and more neonatal intensive care units always a good thing?

The study compared regions of the country with a large supply of these units to regions where there were fewer. As you might expect, babies were more likely to survive in regions where there was a moderate supply of these units than in regions where there were very few. But in areas that exceeded the moderate supply, having more specialists and neonatal intensive care beds didn't help. There simply was an oversupply, leading to use of intensive care units when they weren't needed. In other words, having some neonatal intensive care available is good, but there's a point beyond which adding more doesn't help. The researchers noted that intensive testing and treatment for infants who don't need it can lead to errors and complications, and can interfere with bonding between mother and baby.

An editorial accompanying this study in the New England Journal of Medicine suggested that neonatal intensive care units and specialists were proliferating in part for financial reasons. The units are moneymakers for hospitals, and doctors are attracted to the specialty because they can earn more than general pediatricians. The editorialist argued that the situation was "emblematic of how a market-driven health care system with inadequate public planning produces too much of a good thing." We'd argue that this narrow example is emblematic of what's happening in many areas of medicine. Technology is good up to a point, but beyond that point, it's just cost without benefit.

People Who Get Care Don't Need It

How could more care actually make things worse? One of my (Rick's) patients illustrated how things can go awry when people get too much care. This fellow's visit to the emergency room for a nonemergency problem set off a cascade of treatments and serious complications that proved unnecessary.

David Grohman was an elderly retiree who came to the emergency room complaining of difficulty seeing. David had been in the movie industry, and was perhaps prone to dramatizing his complaints. His actual words, he later told me, were, "I'm going blind." Because of David's age, the emergency room doctor was concerned that David might have temporal arteritis. This is a rare condition involving arteries in the head that can cause permanent visual loss. Even though a screening test for temporal arteritis was normal, the doctor was anxious and hedged his bets by starting high doses of prednisone. This potent anti-inflammatory drug is similar to cortisone. Over the next few days, David experienced a well-known complication of prednisone: the new onset of diabetes.

Shortly thereafter, he suffered a severe complication of diabetes: a condition called hyperosmolar coma. He also had psychiatric symptoms that are known to occur with high doses of prednisone. He was hospitalized twice and had a biopsy of his temporal artery. The pathologist read the biopsy as normal, but hedged his interpretation. Because of the prednisone treatment, he couldn't rule out partly treated temporal arteritis. So the hospital doctors continued the prednisone.

When I saw David in the outpatient clinic, I decided to taper the dose of prednisone, which David had now been taking for about two months. When we succeeded in stopping it entirely, David's diabetes and psychiatric symptoms promptly disappeared. He had no further vision complaints, and on detailed questioning, it appeared that the original visual problem was simply presbyopia. This is the common problem of older adults who have difficulty reading or focusing up close.

This seemed to be a story not so much of bad care as of excessive care, initiated by uncertainty and anxiety in the emergency room. Had the emergency room doctor gotten more details about the symptoms and been more comfortable with even slight ambiguity, he might have spared David the serious complications and expensive hospitalizations. Had David waited until the next day and seen a doctor in the regular clinic instead of going to the emergency room at night, different decisions might have been made. In spite of two hospitalizations for life-threatening complications, the hospital doctors didn't seriously question whether the original diagnosis was correct or whether David needed the prednisone. The bias for action overrode obvious signs that the treatment was causing harm and the possibility that the original treatment decision was based on anxiety more than need. David suffered from too much medical care.

Some forms of excessive care, like the overuse of antibiotics, are becoming familiar to the public. Nearly half of all antibiotic prescriptions are for colds and related symptoms, even though most of these conditions are viral infections that don't benefit from antibiotics. Many of these drugs cause occasional side effects, turning useless treatment into harmful treatment. This "prescriptive promiscuity," as one expert calls it, increasingly involves broad-spectrum antibiotics, which kill a wide variety of bacteria. Excessive use of such drugs is a major contributor to the emergence of resistant bacteria: germs that can't be killed with antibiotics. These resistant bacteria are often called "superbugs." So giving antibiotics for colds generally falls into the category of useless therapy that sometimes turns harmful and can make things worse for all of us. Sometimes more isn't better.

It's increasingly apparent that expenditures for health care are only loosely associated with health itself. It's common knowledge that the United States spends more per capita on health care than any other country, yet our life expectancy and infant mortality are worse than those in most European countries and Japan. This in itself may not be a symptom of too much medical care, but it does suggest that higher spending hasn't bought better health.

More surprising to many people is the enormous geographic variability in health-care use within the United States. For example, surgery rates for back pain literally vary all over the map. There's four times more back surgery per 1,000 people in Boise, Idaho, than in Manhattan. Within Washington State, back surgery rates vary sevenfold among the largest counties. Some of the highest rates are in small communities, while the biggest city, Seattle, has a fairly low rate.

Many experts suspect that this means that doctors in some areas do too much back surgery. The employers who pay the bills wonder why they should pay for services that seem to exceed the norm. But it may also be that too little surgery is done in some areas. This could result in unnecessary pain. What surgery rate is right?

To answer that question, we'd like to know what rate gives the best overall health results. However, this information is hard to come by. Like most things that bring us to the doctor, back pain isn't fatal, and the treatments are generally low risk. So we can't just look at death rates to decide what surgery rate is right. However, under the leadership of Dr. Bob Keller, a Maine orthopedist, we studied back surgery results in geographic regions with high, low, and medium rates of back surgery.

We did the study in Maine, where most orthopedic surgeons and neurosurgeons in the state were willing to participate. The results were surprisingly clear. We found the best surgery results, in terms of pain and disability, in the part of the state with the lowest surgery rate. We found the worst results in the area where surgery rates were the highest. The region with a middling surgery rate had middling results.

You may wonder whether surgeons in the low-rate area got better results just because their patients weren't as sick. In fact, this wasn't the case. Before surgery, patients in the low-rate area had equally severe pain and disability, and more abnormalities on spine-imaging tests.

It seemed that the surgeons who were least likely to operate were best at determining which patients would benefit from surgery. They had a higher threshold for recommending surgery, and they got the best results. This in turn suggested that some of the surgery in the high-rate areas was unnecessary or even harmful. Again, sometimes more isn't better.

The possibility that some operations are unnecessary extends well beyond back surgery. International comparisons indicate that U.S. doctors perform surgery at a much higher rate than those in other developed countries. That might be okay if all the operations were beneficial. But an early study of surgical second opinion programs found that almost 18 percent of recommendations for surgery weren't supported by the second evaluation, leading to questions about the need for them in the first place.

A congressional subcommittee concluded that perhaps 2.4 million unnecessary operations are performed annually in the United States, at a cost of $3.9 billion and 11,900 deaths. Using expert criteria, studies have shown high rates of unnecessary heart bypass operations, hysterectomies, pacemaker insertions, and tonsillectomies. Dr. Lucian Leape, a surgeon at the Harvard School of Public Health, worries that the combination of risk and the promise of a dramatic cure gives surgery an aura of excitement. Doctors and patients alike may mentally minimize the risks when a "cure" seems within their grasp.

National statistics confirm that some forms of medical care are inherently risky. In 2000, a national survey showed that a leading reason for hospitalization was complications from surgically implanted devices and grafts. These complications trailed only various forms of heart disease, pneumonia, and childbirth as a reason why people landed in the hospital. Adding complications from other types of medical treatment gave a staggering total. Treatment complications accounted for 914,000 hospitalizations, at a cost of $19 billion. Many of these complications were probably due not to errors, but to the inherent risks of medical treatment. This isn't a reason to avoid medical care, but it argues for caution.

Some People Who Need Care Get Too Much

Like excessive antibiotic use, the complaint of overly aggressive care for terminally ill patients is becoming a familiar story. Some patients die with monitors, catheters, and intensive care that neither the patient nor the family wants. Such patients may be overtreated but under-cared for.

In a study of hospitalized patients over age eighty, researchers examined preferences for care and actual treatment in four hospitals scattered throughout the United States. Most of the patients who died in the hospital said that they didn't want aggressive care. Fully 70 percent wanted care that was focused on comfort rather than on prolonging life, suggesting that only 30 percent preferred life-sustaining treatments.

Editorial Reviews

Foreword: "This cautionary book warns consumers, doctors, pharmaceutical executives, politicians, and the media all to step back and prevent this medical carousel from going any faster."

From the Publisher

"This book is timely and important"

The Oklahoman

"Hope or Hype is a thoughtful, practical, and practice-oriented guide for the empowerment of physicians. This writing is lively, plainspoken yet intellectual, and sizzles with an uncommon portion of common sense. I urge you to read it and to discuss it with your patients, clinical partners, family, patient advocates, and legislators."

The Journal of the American Medical Association

"This cautionary book warns consumers, doctors, pharmaceutical
executives, politicians, and the media all to step back and prevent this
medical carousel from going any faster."